Onychomadesis in a 20-Month-Old Child with Kawasaki Disease

15 Mar, 2019 ,
Case Reports in Pediatrics
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Case Reports in Pediatrics
15 Mar, 2019 ,

A 20-month-old boy was suffering from high-spiking fevers since 7 days. Examination revealed  bilateral nonpurulent bulbar conjunctival injection; fissured red lips; strawberry tongue diffuse erythema of the oropharyngeal mucosa; a generalized blanching polymorphous maculopapular rash over his face, trunk. He also had oedema of hands and feet. Based on investigations and examination findings a daignosis of Kawasaki Disease was made. The child was treated with IV immunoglobulin and oral high-dose aspirin and showed gradual recovery. 

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A 20-month-old Chinese boy was seen with a 7-day history of high-spiking fevers. The child broke out with a nonpruritic widespread reddish rash 1 day after the onset of fever. On the third day of the fever, he developed nonpurulent conjunctival injection. The child was irritable and had decreased oral intake. His mother brought him to see a family physician who treated the child with azithromycin and acetaminophen. The fever persisted in spite of the treatment. The child had not been exposed to anyone with a known infectious disease. His past medical history was unremarkable. The family history was noncontributory.

On examination, the child was irritable and lethargic. His weight was 10.4 kg, height 82 cm, and head circumference 48.5 cm. His temperature was 39°C, heart rate 115 beats per minute, blood pressure 84/40 mm·Hg, and respiratory rate 33 breaths per minute. The child was noted to have bilateral nonpurulent bulbar conjunctival injection; fissured red lips; strawberry tongue diffuse erythema of the oropharyngeal mucosa; a generalized blanching polymorphous maculopapular rash over his face, trunk, and groin; erythema and firm edema of the dorsa of the hands and feet with sharp demarcation at the ankles and wrists and two enlarged firm tender lymph nodes each measuring 2 × 3 cm in the right cervical area. The rest of the physical examination was normal. In particular, there was no hepatosplenomegaly or a heart murmur.

The child was admitted to the hospital for investigations and management. Laboratory tests on admission revealed the following results: hemoglobin 12.6 g/dL (126 g/L), white blood cell count 21.3/μL (×109/L) with 88% neutrophils, platelet count 277 × 103/μL (×109/L), and C-reactive protein 21.2 mg/L (201.7 nmol/L). Urinalysis showed 15 white blood cells per high-power field with no bacteria. Serum electrolytes, albumin, liver enzymes, and renal function were normal. Urine culture and throat swab culture were negative. The baseline chest radiograph, electrocardiograph, and echocardiograph were normal.

A diagnosis of Kawasaki disease was made based on the findings of fever for seven days, conjunctival injection, polymorphous rash, oral mucosal changes, changes in extremities, and cervical lymphadenopathy. The child was treated with intravenous immunoglobulin (2 g/kg) infused over 12 hours and high-dose aspirin (80 mg/kg/day divided into 4 doses) given orally. Over the next 36 hours, the child became afebrile, and the maculopapular rash resolved completely.

He was discharged after 4 days of hospitalization on high-dose aspirin (80 mg/kg/day divided into 4 doses) for a total of 14 days followed by low-dose aspirin (4 mg/kg/day) in once-daily dosing for 8 weeks. At 2-month follow-up, the child’s fingernails and toenails were found to be partially shed on both hands and feet, with the proximal nail beds covered by new nail. At 4-month follow-up, the old fingernails and toenails were fully shed, and the new fingernails and toenails were normal. Follow-up echocardiogram at 4 weeks and 3 months was normal.